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    Acute Angle Closure Glaucoma – Diagnosis and Treatment


    Last Updated Dec 27, 2022
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    First 5 Minutes

    Acute angle-closure glaucoma is an ocular emergency. If left untreated, it may lead to blindness.

    1. Call ophthalmology for emergent consultation. They may wish to dictate medical treatment before further procedures/surgery.
    2. Treat patient with the following:
      1. Timolol 0.5% 1 drop q15min for 2-3 doses in affected eye only.
      2. Brimonidine 0.1-0.2% 1 drop or apraclonidine 0.5% 1 drop q15min for 2-3 doses in affected eye only.
      3. Pilocarpine 2% 1 drop to affected eye.
      4. Acetazolamide 500mg PO/IM/IV then 250mg PO/IM/IV q6h.
      5. Mannitol 0.5-2g/kg IV over 20 minutes if no response to other medications.
    3. Measure IOP every 60 minutes.


    Acute angle-closure glaucoma (symptomatic) is a clinical condition that occurs in <30% of patients with closed-angle glaucoma (asymptomatic).

    Acute angle-closure glaucoma is symptomatic and characterized by conjunctival hyperemia, corneal edema, a shallow anterior chamber, and very high intraocular pressures (typically >30mmHg).

    Symptoms of acute angle-closure glaucoma include ocular pain, nausea/vomiting, and vision changes (most notably blurring with light halos).

    It is an ocular emergency that with delayed treatment (even several hours) can cause chronic glaucoma, permanent retinal vascular occlusions, optic atrophy, and permanent blindness.

    Risk factors include female sex, older age, Asian ethnicity.

    Diagnostic Process

    Diagnosis is based on tonometry demonstrating elevated intraocular pressure.

    The presumptive diagnosis can be made for an IOP >30mmHg (other sources suggest 21mmHg). There is rarely acute vision loss and pain with pressures <50mmHg.

    No role for imaging.

    Clinical Features:

    1. Painful, red eye
    2. Blurring of vision
    3. Headache
    4. Nausea and vomiting

    On Examination:

    1. Hazy cornea due to high IOP
    2. Mid-dilated, poorly/non-reactive pupil
    3. Dull corneal reflex
    4. Shallow anterior chamber
    5. Increased IOP of >30mmHg (normal 6-22mmHg)
    6. Reduced visual acuity

    Recommended Treatment

    Patient should be treated in the emergency department with topical and systemic medications to temporize damage to the optic nerve.

    Ophthalmology should then be involved for definitive management in the form of iridotomy.

    Medication Classes

    1. Prostaglandin Analogues (e.g. latanoprost)
    2. Beta-blockers (e.g. timolol)
    3. Alpha-agonists (e.g. brimonidine, apraclonidine)
    4. Carbonic anhydrase inhibitors (e.g. acetazolamide, dorzolamide)
    5. Cholinergic agonists (e.g. pilocarpine)

    Medical Management

    1. Timolol 0.5% 1 drop q15min for 2-3 doses in affected eye only
    2. Brimonidine 0.1-0.2% 1 drop or apraclonidine 0.5% 1 drop q15min for 2-3 doses in affected eye only
    3. Pilocarpine 2% 1 drop to affected eye
    4. Acetazolamide 500mg PO/IM/IV then 250mg PO/IM/IV q6h
    5. Mannitol 0.5-2g/kg IV over 20 minutes if no response to other medications

    Ultimately, patients require referral to ophthalmology for laser peripheral iridotomy, a procedure which creates a whole in the iris to allow drainage of aqueous humor.

    Criteria For Hospital Admission

    Dictated by ophthalmology. Patients whose intraocular pressure is not responsive to medical management will require emergent iridotomy or surgery.

    Criteria For Transfer To Another Facility

    Patients with acute angle-closure glaucoma require emergent ophthalmology consultation. This may require transport depending on your centre.

    Criteria For Close Observation And/or Consult

    All patients with acute angle-closure glaucoma require urgent consultation by ophthalmology.

    Criteria For Safe Discharge Home

    Patients will require definitive management by ophthalmology within 24 hours. Disposition should be determined by the consulting ophthalmologist.

    Quality Of Evidence?


    Clinical Features and Background Information 

    This information is based on a systematic review of 210 articles between Jan 2000 and Sept 2013.  Results were published in JAMA.


    Treatment of Acute Angle Closure Glaucoma

    Current treatment of this condition is based primarily on clinician experience and expert opinion. There are no large trials available that compare topical or systemic treatment options.


    Related Information

    Reference List

    1. Petsas A, Chapman G, Stewart R. Acute angle closure glaucoma – A potential blind spot in critical care. J Intensive Care Soc. 2017;18(3): 244-246. 10.1177/1751143717701946

    2. Ah-kee, EY, Egong E, Shafi A, Lim LT, Yim JL.  A review of drug-induced acute angle closure glaucoma for non-ophthalmologists. Qatar Med J. 2015. 2015(6): 1-8. 10.5339/qmj.2015.6

    3. Weinreb RN, Aung T, Medeiros FA.  The Pathophysiology and Treatment of Glaucoma: A Review. JAMA. 2014;311(18):1901-1911. doi:10.1001/jama.2014.3192

    4. Hammond VM, Mattu A, Swadron S. Acute Glaucoma. EM RAP. October 14, 2022.  Accessed December 8, 2022.  https://www.emrap.org/corependium/chapter/recQnDsM14OI8Vjzy/Acute-Glaucoma#h.5xi7ezvh1v7o

    5. Shields SR. Managing eye disease in primary care. Postgrad Med. 2000; 108(5): 99-106. 10.3810/pgm.2000.10.1781


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